The Economist USA - 28.03.2020

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54 International The EconomistMarch 28th 2020


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their sessions to learn about covid-19. The
experience at hospitals in China, Italy and
Spain suggests that is prudent. As critical-
care wards in the affected countries were
inundated with coronavirus patients, they
rapidly had to train doctors and nurses
from unrelated specialisms in how to intu-
bate patients and perform other proce-
dures. Dr Caridi-Scheible, whose hospital
is already treating more than a dozen co-
vid-19 patients, warns the medics who are
standing by for their first cases to “call in
every friend and favour you are owed”.
To save the lives of gravely ill patients,
doctors are trying many drugs. They are
bombarded with suggestions from all
kinds of sources online. But as soon as any
particular medication is mentioned, every-
one rushes to buy or use it, even preven-
tively, despite the lack of evidence, says
John Hick from the Hennepin County Med-
ical Centre in Minneapolis. “Until we take
the time to figure out what works, throw-
ing the kitchen sink at every patient might
actually harm them,” he adds. Steroids
were used in the 2003 outbreak of sars, a
respiratory disease caused by another co-
ronavirus, but studies since then suggest
they may in fact have caused some harm.
Reliable answers can only come from
proper clinical trials. Hundreds are under
way. In early March Bruce Aylward, who led
the who’s fact-finding mission to China in
February, said 200 trials had been regis-
tered there. But with so many small trials, it
was difficult to enroll enough patients.
Small trials cannot distinguish a small ef-
fect from chance. Such a lack of data may
explain why a trial of Kaletra, an hivdrug
combination, in patients with severe co-
vid-19 was not conclusive, says Ana Maria
Henao Restrepo of the who. Trials from
China may yet bear fruit. The earliest, in se-
verely ill patients treated with remdesivir,
a drug developed to treat Ebola, is due to
finish collecting data on April 3rd.
What is really needed is a large, interna-
tional trial that collects data about lots of
drugs from many hospitals. The who
hopes that a trial it announced on March
20th will do so. It will test four different
possibilities: remdesivir, chloroquine, Ka-
letra, and Kaletra plus interferon beta, the
drugs which currently seem to hold most
promise. The hope is that medics, even
those working under great pressure, will
recruit patients. Patients are enrolled
through the who’s website, which will ran-
domly assign each of them to a trial drug
(which will be limited to those that are
available at the time).
The trial is “adaptive”, so it will change
as results come in. Data will be monitored

by an independent board. Ineffective treat-
ments will be dropped and replaced by
more promising ones. This will allow the
best treatments to be compared swiftly.
After patients are enrolled in the trial,
doctors need only record a few data points.
When did each patient leave hospital or
die? After how long? Did the patient need
oxygen or ventilation?
There will be no placebo and doctors
will know which treatment has been given
to which patient. Those are not features of
high-quality clinical trials in normal
times. But the design is the best way to find
out in the shortest time which of a number

of drugs works best. The whohas not said
how long it expects the trial to take. Coun-
tries including Argentina, Bahrain, Cana-
da, Iran, Norway, South Africa, Spain, Swit-
zerland and Thailand have already said
they will join. Some 3,200 European pa-
tients will participate under the co-ordina-
tion of a French biomedical research agen-
cy. Other international trials are being
planned—for example, to determine
whether the drugs being tested in patients
work to prevent illness when taken by
health-care workers. The pace of discovery
is unprecedented. But the stakes could
hardly be higher. 7

O


ne of themost worrying symptoms of
covid-19 is the way the coronavirus at-
tacks the lungs of those infected. This
means some patients need a ventilator to
help them breathe until their lungs recov-
er. But there is a dire shortage of these ma-
chines in hospitals, so intensive-care units
will be overwhelmed. Urged on by worried
governments, ventilator manufacturers
are working flat out and forming partner-
ships with carmakers, aerospace firms and
others to boost output as fast as possible.
But their efforts will still be not enough
to meet soaring demand. So hope is riding
on scores of new projects to develop
breathing devices that could be made rap-
idly by non-specialist companies and
small workshops. These are mostly sim-
pler devices; some could even be assem-
bled by diyenthusiasts. The response to
this call to arms is unprecedented.
Yet difficulties and dangers lie ahead. At
present ventilation is about the only way
doctors have to treat those who are serious-
ly ill from the novel coronavirus, and the
shortage of available machines is terrify-
ing. In America the Society of Critical Care
Medicine estimates that roughly 200,000
ventilators may be available, though many
are older machines that have been in stor-
age and may not be capable of supporting
patients with severe respiratory failure. By
some estimates, nearly 1m Americans may
need mechanical ventilation at the peak of
the country’s covid-19 epidemic. And the
number of potentially critically ill patients
who need ventilating could be much high-
er. At some point the people needing venti-
lators will probably far outnumber the ma-
chines available. Similar shortages exist in
other countries, and in some parts of the

world the number of ventilators in a hospi-
tal can be counted on one hand.
In their desperation some doctors are
trying to connect more than one patient to
a single ventilator, even though manufac-
turers do not recommend this because in-
dividual patients need different levels of
breathing support.
Ventilators work by pumping air, mixed
with additional oxygen as required by the
patient, into the lungs. Carbon dioxide is
expelled as the lungs contract. The air can
be supplied to a patient via a mask. If more
breathing support is needed, a tube is in-
serted down the patient’s trachea and into
his or her airways, a process known as intu-
bation. Alternatively, air can be delivered

Scientists and industry are rallying to make more urgently needed ventilators

Hospital ventilators

Wind rush


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